Executive Summary

2012- Waterloo-Wellington Diabetes RCC Annual Report 2013 Executive Summary Debbie Hollahan, Regional Director Waterloo Wellington Diabetes Regional Coordination Centre January 31, 2013 Executive Summary 2012- 2013 Background The Waterloo Wellington Diabetes Regional Coordination Centre (DRCC) was established in 2010, through funding from the Ontario Diabetes Strategy with the Ministry of Health and Long Term Care (MOHLTC). Langs Farm Village Association (Langs) was selected as the host organization for the DRCC in Waterloo Wellington. The role of the DRCC is to provide regional leadership to integrate and coordinate diabetes care in the region of Waterloo-Wellington, including primary care, diabetes programs, endocrinologists, and the community. The DRCC works closely with the Local Health Integrated Network (LHIN) to provide a clear point of contact within each region for diabetes. The DRCC does not provide direct patient services, but drives the implementation of provincial priorities while monitoring regional performance. The goal of the DRCC is to improve the delivery of care for people and families living with diabetes. In 2010, a workplan was established in the form of a logic model, using the framework of the Chronic Disease Prevention and Management (CDPM) Framework (Fig. 1) and incorporating the principles from Health Quality Ontario—“Safe, integrated, Patient-Centred, Accessible, Equitable, Effective and Efficient”. The Ontario CDPM framework (Fig. 1) is a validated tool which provides a model for system planning for chronic disease prevention and management. The “bubbles” within the framework provide a structure for effective planning of activities. The following report is presented under headings that mirror this CDPM framework. Figure 1: Ontario CDPM Framework 2 | P a g e January 2013 Executive Summary 2012- 2013 For 2012-13, work continued, building on the successes to date, and focusing on the identified priorities established in the past year, with a greater focus on the social determinants of health. Priorities continued to focus on the following three areas: Quality Improvement Primary Care Engagement System Integration In October 2012, Langs received notice of termination of contract for the DRCC from the Ministry of Health and Long Term Care (MOHLTC), as the responsibility for the delivery of the DRCC was transitioning to the LHIN. DRCC staff were given 90 days notice of termination of employment, and as a result, many of the projects were placed on hold, while winding down the DRCC. Major Accomplishments in 2012-13 The DRCC steering committee continued to meet regularly, up until January 2013, to help guide and support the work of the DRCC. They all expressed the desire to continue the steering committee, but suggested changing the title to a diabetes advisory network, as they felt the strength and collective voice of the group was very important as the DRCC was transitioning. Membership on the steering committee included representation from the whole region, including diabetes educators, managers, specialists, pharmacist, regional renal director, CCAC, health promotion, LHIN, and the CDA (App. 2). Self-Management Support In the spring of 2011, funding was received from the MOHLTC through the Ontario Diabetes Strategy to support the coordination of Self-management training and programs for both individuals with diabetes as well as health care providers. In 2012, the programming was expanded to include all chronic diseases. This funding and programming continues to be provided directly from the MOHTLC to Langs, so was not impacted by the DRCC transition. The funding supports two components: 1. Coordination of Programs for Individuals with Diabetes The "Take Charge" program was developed which included coordination of the Stanford "Living Well with Chronic Disease" programs. This program was previously being offered by a number of organizations in the region with each organization having individual licenses. Considerable work has 3 | P a g e January 2013 Executive Summary 2012- 2013 been done to coordinate all of the programs through a central registration, which is done through the web-site http://www.wwselfmanagement.ca/ 2. Coordination of Programs Health Care Providers The “Moving Towards Change” program was created with 3 workshops provided annually. This program is a tailored program for health care professionals to gain the skill-set required to empower behavioural change and to support patients to self-manage their chronic disease. Program includes: . 1 ½ day training by an expert psychologist , Dr. Michael Vallis, specialized in behavioural change and diabetes . 5 follow-up mentorship sessions in the clinic setting by a consultant psychologist, Dr. Shannon Currie, to help build and support confidence and knowledge Another program is being developed with a "train the trainer" approach to have a greater reach and sustainability. Delivery System Design Central Intake The centralized intake process for diabetes education referrals has been very successful to date with just under 4,000 referrals to date. The process offers a streamlined process for referrals to diabetes education programs including one referral form (or self-referral form) and one central number. The program ensures people are provided “the right care at the right place at the right time”. The program also provides monitoring of wait-times and maximization of resources as the referrals are triaged and distributed according to established criteria and defined roles of programs. In November 2012, the referral form and process were expanded to receive referrals to endocrinologists/diabetes specialists. This allows the referring primary care provider to only refer once, and it also improves communication to all providers in the "circle of care". Wait-times are monitored and reported back to the Diabetes Education Programs to support them in meeting the standards for wait times. To date: 3,855 referrals 73 self-referrals 363 referral sources 4 | P a g e January 2013 Executive Summary 2012- 2013 A proposal was submitted to the LHIN and approved by the LHIN board January 31st, 2013, to maintain direct service components of the DRCC, including central intake, mentoring and web-site maintenance at Langs. This secured the resources to prevent any lapse in service. Diabetes in Pregnancy Research on diabetes in pregnancy for the region demonstrated that there is no consistency in the management and care among programs and was identified as a concern from many of the diabetes specialists in the region. Data shows poor outcomes for women with diabetes in pregnancy in the region, such as large for gestational age birth-weights, and higher rates of C-sections. An advisory panel (App. 3) of endocrinologists, obstetricians, midwives, family physicians, nurse practitioners diabetes educators and managers was developed to provide guidance to the DRCC on the development of a strategic plan and pathway for diabetes in pregnancy. A team including Trina Fitter RD from Groves Memorial Hospital and Amy Waugh RD from Upper Grand FHT, worked closely with the DRCC in developing the pathway and sharing their results from work they have completed in analyzing post-partum gestational diabetes care. The development of a pathway was in progress, along with supporting documents, such as pre-printed orders for labour and delivery and a patient passport. Further meetings with the advisory panel and development of the pathway are on hold as a result of the transition of the DRCC. The group from Fergus continue to work collaboratively with CMH staff in developing physician orders. Provider Decision Support Mentoring Support With many newer educators in community programs, there was a limited amount of experience in complex diabetes management as they had the knowledge, but were limited with their skill or confidence, which is gained through experience. A mentoring program was piloted last year through an educational grant from NovoNordisk, and as a result of successful outcomes, funding was secured from the MOHLTC to sustain the program. An experienced certified diabetes educator (CDE), Wendy Graham, supports educators and health care providers in their own clinic setting, to gain the knowledge, skill and judgment required to provide effective complex diabetes management including insulin initiation and titration. 15 organizations and 56 staff have participated in the mentoring program. There are currently 83 Certified Diabetes Educators (CDE’s) in the region. The successes and outcomes of the program were presented at a poster presentation at the national CDA conference in Vancouver in October 2012. This program is continuing with Langs, through funding from the LHIN. 5 | P a g e January 2013 Executive Summary 2012- 2013 Directory of Services A printed Directory of Services was developed in partnership with the CDA, and distributed to all physicians and diabetes education programs in the region. Hard copies are also available to the public or on our web-site. Educational Events Several education events were held to support educators, with representation throughout the region. An event, “Getting to the Business Side of Your Diabetes Education Centre", was delivered with a focus on the importance of data collection, monitoring and quality improvement to deliver effective education and to meet the increasing volumes of referrals. The provincial DRCCs partnered with the Seniors Health Knowledge Network (SHRTN) to deliver monthly Diabetes 101 webinar series to long term

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